Internal Audit Quality Assessment. Presented To: Houston Independent School District

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1 Internal Audit Quality Assessment Presented To: Houston Independent School District July 2013

2 Table of Contents Executive Summary Opinion as to Conformance to the Standards Objectives / Scope / Methodology IIA Standards Conformance Summary Conformance Gaps Noted and Associated Recommendations 7 Page 3 Attachment A Conformance Rating Criteria Attachment B Acronyms Used in Report

3 Executive Summary Under the International Standards for the Professional Practice of Internal Auditing ( Standards ) an external quality assessment ( EQA ) of an internal audit activity must be conducted at least once every five years by a qualified assessor or assessment team from outside the organization. The qualified assessor or assessment team must demonstrate competence in both the professional practice of internal auditing and the EQA process. The Houston Independent School District ( HISD ) Board Audit Committee selected the Institute of Internal Auditors ( IIA ) to lead the review of the Office of Inspector General ( Internal Audit ). The review was concluded on March 28, 2013 and provides management with information about Internal Audit as of that date. Future changes in environmental factors and actions by personnel, including actions taken to address recommendations, may have an impact upon the operation of Internal Audit in a manner that this report did not and cannot anticipate. Considerable professional judgment is involved in evaluating the findings and developing recommendations. Accordingly, it should be recognized that others could evaluate the results differently, and draw different conclusions. The criteria used to determine conformance to the Standards are defined on page 36 of this report and are consistent with the guidance provided by the IIA in their Quality Assessment Manual, Sixth Edition. Opinion as to Conformance to the Standards It is our overall opinion that Internal Audit does not conform to the Standards. Does Not Conform means the assessor has concluded that the internal audit activity is not aware of, is not making good-faith efforts to comply with, or is failing to achieve many / all of the objectives of the Standards. While an Internal Audit charter is in place to establish the purpose, authority, and responsibility of Internal Audit, it is outdated and not consistent with requirements of the Standards. While Internal Audit reports functionally to the Board and administratively to the Superintendent, the nature of the functional reporting relationship is not described in the charter. The charter is not consistent with the Definition of Internal Auditing, the IIA Code of Ethics, and the Standards and is not updated periodically and approved by the Board. This is a critical element to ensure functional reporting is effective and organizational independence is achieved. Documentation of planning and preliminary risk assessment at an engagement level does not support that work is done with due professional care and IT audit resources and skills need to be evaluated. The CAE has not established, documented and maintained a Quality Assurance and Improvement Program ( QAIP ) that includes the required elements of internal and external assessment and communication of the results of such assessments. The annual risk assessment and audit planning process is not effective in prioritizing areas for audit. There is limited input from key stakeholders when conducting the risk assessment and developing the annual audit plan, the plan is not clearly linked with an entity-wide view of risk, and there is no linkage between audit plan objectives and supporting resource requirements. The annual audit plan is not shared with key stakeholders in the organization beyond the Board Audit Committee. Concepts of governance, risk management, and control are not specifically addressed in the audit plan. An internal audit methodology has not been specifically defined and documented for Internal Audit to ensure that infrastructure and processes are consistent with the Standards and that work can be performed efficiently, effectively, consistently, and with a high level of quality. Planning for individual engagements, supported by an engagement level risk assessment, is not defined and or documented in audit work papers. Audits are executed based upon an approved work program, but are inconsistent in terms of quality and level of documentation supporting conclusions. Audit reports could be enhanced by including recommendations for management action and by improving timeliness, especially related to E-Rate matters. There is no formal follow-up process to monitor the status of observations raised during the audit reporting process. 3

4 Executive Summary Objectives / Scope / Methodology The principal objectives of the EQA were to (1) assess Internal Audit conformance to the Standards; (2) assess the effectiveness of Internal Audit in providing assurance and advisory services to the Board, senior executives, and other interested parties; and (3) identify opportunities, offer recommendations for improvement, and provide counsel to the Chief Audit Executive ( CAE ) and staff for improving their performance and services and promoting the image and credibility of Internal Audit. The scope of the assessment included Internal Audit, as set forth in the Internal Audit charter. Conformance criteria used were the Standards. To accomplish the objectives, the EQA team reviewed information prepared by Internal Audit at the EQA team s request, conducted interviews with selected key stakeholders to Internal Audit, reviewed a sample of audit projects and associated work papers and reports, reviewed benchmark and survey data, and prepared diagnostic tools consistent with the methodology established for an EQA in the IIA Quality Assessment Manual, Sixth Edition. This external quality assessment was commissioned by the Board Audit Committee and is the first external quality assessment performed for Internal Audit and which was designed to evaluate conformance with the Standards. The external quality assessment evaluated Attribute Standards that describe requirements for infrastructure supporting Internal Audit and include elements such as (1) the Internal Audit charter that is the foundational document describing the purpose, authority, and responsibility of the activity; (2) organizational placement of Internal Audit and their ability to operate independently and objectively; (3) processes and infrastructure to ensure that work is performed with proficiency and due professional care; and (4) processes to support quality and continuous improvement within Internal Audit. The external quality assessment also evaluated Performance Standards that describe management and other processes that support the actual conduct of internal audits and include (1) activities associated with managing the internal audit activity such as annual audit planning, resource management, coordination of activities with other providers of assurance, and defining the internal audit methodology; (2) the scope of internal audit including governance, risk management, and control; (3) processes for planning audit engagements; (4) processes for executing engagements; (5) processes for communicating results of engagements; (6) processes for monitoring management actions on reported observations; and (7) mechanisms to communicate the acceptance of risk by management to the Board. 4

5 Executive Summary Detailed observations related to conformance gaps for the Standards are included on the following pages. We have provided recommendations to address each conformance gap noted. Also included are Internal Audit responses provided to us that include commitments to action and timeframes for meeting those actions. The Board Audit Committee should monitor the status of committed action until all committed actions have been completed. Thank you for the opportunity to be of service to HISD. We will be pleased to respond to further questions concerning this report and furnish any desired information. Basil Woller, CIA, CRMA Team Leader Team Members: David MacCabe, CIA, CGAP, CRMA Robert Shipway, CIA, CRMA Debi Roth, CIA Director, Quality The Institute of Internal Auditors 5

6 Attachment A IIA Standards Conformance Summary OVERALL ATTRIBUTES STANDARDS GC PC DNC 1000 Purpose, Authority, and Responsibility X 1010 Recognition of the Definition of Internal Auditing X 1100 Independence and Objectivity X 1110 Organizational Independence X 1111 Direct Interaction with the Board X 1120 Individual Objectivity X 1130 Impairments to Independence or Objectivity X 1200 Proficiency and Due Professional Care X 1210 Proficiency X 1220 Due Professional Care X 1230 Continuing Professional Development X 1300 Quality Assurance and Improvement Program X 1310 Requirements of the Quality Assurance and Improvement Program 1311 Internal Assessments X 1312 External Assessments X 1320 Reporting on the Quality Assurance and Improvement Program X 1321 Use of Conforms with the International Standards for the Professional Practice of Internal Auditing 1322 Disclosure of Nonconformance X PERFORMANCE STANDARDS 2000 Managing the Internal Audit Activity X 2010 Planning X 2020 Communication and Approval X 2030 Resource Management X 2040 Policies and Procedures X 2050 Coordination X X X X X X GC PC DNC 2060 Reporting to Senior Management and the Board X 2070 External Service Provider and Organizational Responsibility for Internal Auditing 2100 Nature of Work X 2110 Governance X 2120 Risk Management X 2130 Control X 2200 Engagement Planning X 2201 Planning Considerations X 2210 Engagement Objectives X 2220 Engagement Scope X 2230 Engagement Resource Allocation X 2240 Engagement Work Programs X 2300 Performing the Engagement X 2310 Identifying Information X 2320 Analysis and Evaluation X 2330 Documenting Information X 2340 Engagement Supervision X 2400 Communicating Results X 2410 Criteria for Communicating X 2420 Quality of Communications X 2421 Errors and Omissions X 2430 Use of Conducted in Conformance with the International Standards for the Professional Practice of Internal Auditing 2431 Engagement Disclosure of Nonconformance X 2440 Disseminating Results X 2450 Overall Opinions NA 2500 Monitoring Progress X 2600 Communicating the Acceptance of Risks X NA X 6

7 Conformance Gap Noted Standard 1000 The Office of Inspector General ( Internal Audit ) Charter must be revised to conform to the requirements of Standard 1000 Purpose, Authority, and Responsibility. While the Internal Audit Charter defines the purpose, authority, and responsibility of Internal Audit in a very broad manner, the concepts embodied within the Definition of Internal Auditing, the IIA Code of Ethics, and the Standards are not specifically included or referenced in the document. In addition, the CAE does not periodically review the Internal Audit Charter and present it to senior management and the Board for approval. Further, the Internal Audit Charter does not establish the functional reporting relationship of Internal Audit to the Board and does not describe the nature of that functional reporting relationship. While the nature of assurance and consulting services provided can be inferred in the document, they are not specifically defined as required. Associated Recommendations Standard Revise the Internal Audit Charter to conform to all the requirements of Standard 1000 Purpose, Authority, and Responsibility. Upon revision, present to the Board for review and approval. Consider using the IIA Model Internal Audit Activity Charter as the template for this revision. The Internal Audit Charter is the foundational document that supports and guides all activities for the function and must be current and consistent with the Definition of Internal Auditing, the IIA Code of Ethics, and the Standards. Leading internal auditing practice suggests that review and approval of the Internal Audit Charter by the Board be done on an annual basis. This ensures that the Internal Audit Charter is updated in a timely manner as changes in the International Professional Practices Framework ( IPPF ) become effective. In addition, this demonstrates an appropriate tone at the top related to Board fiduciary oversight over Internal Audit. 2. Ensure that the Internal Audit Charter defines and describes the nature of the functional reporting relationship of Internal Audit to the Board consistent with the examples provided in the interpretation to Standard 1110 Organizational Independence. 3. Ensure that the nature of assurance and consulting services provided by Internal Audit are clearly articulated in the Internal Audit Charter document. Management Response and Commitment to Action Standard No later than November 30, 2013, the HISD s Board of Education ( Board ) shall revise the Internal Audit Charter as found in HISD Board Policy CFC (LOCAL) to conform with the guidelines described in IIA Standard 1000 Purpose, Authority, and Responsibility which states, The purpose, authority and responsibility of the internal audit activity must be formally defined in an internal audit charter, consistent with the Definition of Internal Auditing, the Code of Ethics and the Standards. The chief audit executive must periodically review the internal audit charter and present it to senior management and the board for approval. 2. HISD is an independent special-purpose government authorized by the State of Texas to operate local public schools. The Board of Education, the Board s Audit Committee, and the Office of Inspector General shall also follow all applicable laws, rules, and regulations of the State of Texas. They shall also utilize and reference the guidelines and standards of the IIA, AICPA, TEA, and GAGAS as appropriate. However, the Office of the Inspector General shall report directly to the Board of Education through the Board Audit Committee and not to administration (senior management). Further, the Office of the Inspector General shall be independent, and internal auditors must be objective in performing their work. (Continued on next page) 7

8 Management Response and Commitment to Action Standard 1000 (Continued from previous page) 3. No later than November 30, 2013, the Board Audit Committee shall revise the Audit Committee Charter as currently described in HISD Board Policy BDB (LOCAL) to include examples of functional oversight over Internal Audit consistent with the IIA Model Audit Committee Charter. Functional oversight of Internal Audit included in the Audit Committee Charter BDB (LOCAL) or HISD Board Policy BAA (LOCAL) should be consistent with the functional oversight described in the Internal Audit Charter found in the to be revised HISD Board Policy CFC (LOCAL). 4. The Office of Inspector General shall confirm to the Board Audit Committee on an annual basis the organizational independence of the internal audit activity. The Office of Inspector General shall be responsible for creating, periodically reviewing, and if necessary, revising the Internal Audit Charter in collaboration with the Board Audit Committee. Any revisions to the Internal Audit Charter shall be presented to the Board Audit Committee and the Board of Education for review and approval, and the Office of the Inspector General shall communicate and collaborate with the Superintendent and administration regarding the Internal Audit Charter to gather relevant and pertinent input, and any and all information gathered shall be reported to the Board Audit Committee. The Internal Audit Charter shall be used by HISD as a foundational document that supports and guides all activities for the function of internal auditing. Review and approval of the Internal Audit Charter shall be done on an annual basis in December to ensure compliance with up-to-date guidelines and standards. The Board of Education and the Board Audit Committee shall demonstrate a strong commitment to fiduciary oversight over internal audit. 5. The Internal Audit Charter shall define and describe the nature of the functional reporting relationship of the Office of the Inspector General to the Board of Education through the Board Audit Committee. Functional reporting to the Board of Education involves the Board Audit Committee: 1) Approving the Internal Audit Charter; 2) Approving an Annual Risk-Based Internal Audit Plan; 3) Approving the Office of Inspector General s budget and resource plan; 4) Approving decisions regarding the appointment and removal of the Inspector General; 5) Approving the remuneration of the Inspector General and Office of Inspector General staff; and 6) Making appropriate inquiries of the Office of Inspector General to determine whether there are inappropriate scope or resource limitations. The Board Audit Committee shall communicate with the Inspector General on the internal audit activity s performance relative to its plan and other matters. The Board Audit Committee shall also monitor and evaluate the performance of the Office of Inspector General on an annual basis. 6. The Board of Education shall ensure that the nature of assurance and consulting services provided by the Office of Inspector General are clearly articulated in the Internal Audit Charter. 8

9 Conformance Gap Noted Standard 1010 The Internal Audit charter does not reference the mandatory nature of the Definition of Internal Auditing, the IIA Code of Ethics, or the Standards as required by Standard In addition, there is no evidence to support that the CAE has discussed the Definition of Internal Auditing, the Code of Ethics, and the Standards with senior management and the Board. Associated Recommendations Standard Reference the mandatory nature of the Definition of Internal Auditing, the IIA Code of Ethics, and the Standards in the Internal Audit charter. These are mandatory elements of the IPPF and are foundational to the practice of internal auditing in an organization. 2. Discuss the Definition of Internal Auditing, the IIA Code of Ethics, and the Standards with senior management and the Board on a periodic basis concurrent with the recommended review and approval of the Internal Audit charter on an annual basis. Management Response and Commitment to Action Standard The Internal Audit Charter shall reference the mandatory nature of the Definition of Internal Auditing, the IIA Code of Ethics, and the Standards. The Internal Audit Charter shall also reference and comply with standards and guidelines set forth by the AICPA, TEA and GAGAS as appropriate. 2. The Office of Inspector General shall discuss the Internal Audit Charter including the Definition of Internal Auditing, the Code of Ethics, and the Standards with the Board Audit Committee and senior management on a periodic basis concurrent with the recommended review and approval of the Internal Audit Charter done on an annual basis. 9

10 Conformance Gap Noted Standard 1110 Characteristics of organizational independence for Internal Audit do not include all the elements necessary to fully conform to the Standards. Approval of the Internal Audit charter is not included as a Power or Duty of the Board as documented in Board Policy BAA (LOCAL) or as a specific responsibility of the Board Audit Committee as documented in Board Policy BDB (LOCAL). While the annual audit plan is approved by the Board Audit Committee in closed session, it is not reported out to the Board and included as an action in the Board minutes to document that such action took place. Performance of the CAE is not included as a functional responsibility of the Board or Board Audit Committee and does not take place on an annual basis. While Internal Audit is free from interference in determining the scope of internal auditing, performing work, and communicating results, this aspect of organizational independence is not described in the Internal Audit charter. Lastly, there is no specific evidence that the CAE confirms the organizational independence of Internal Audit to the Board on an annual basis as required by Standard This is especially critical since the role of Inspector General within HISD combines the role of the CAE responsible for Internal Audit with the role of Inspector General charged with responsibility for investigative matters. Guidance for these potentially conflicting roles can be found in the IIA Position Paper The Three Lines of Defense in Effective Risk Management and Control (January 2013). Associated Recommendations Standard Add the responsibility to approve the Internal Audit charter to either Board Policy BAA (LOCAL) or BDB (LOCAL). As described in the recommendation related to Standard 1000, this approval should take place on an annual basis. 2. Add the responsibility to evaluate the performance of the CAE on an annual basis to either Board Policy BAA (LOCAL) or BDB (LOCAL). 3. Report approval of the annual audit plan to the Board when approval takes place in closed session and document this approval in Board minutes. 4. Include a statement in the Internal Audit charter that Internal Audit is free from interference in determining the scope of internal auditing, performing work, and communicating results. 5. Confirm the organizational independence of Internal Audit to the Board on an annual basis as required by Standard Evaluate the organizational structure of the Office of Inspector General with consideration given to the IIA Position Paper The Three Lines of Defense in Effective Risk Management and Control (January 2013). This Position Paper is strongly recommended but not mandatory professional guidance that describes the role of Internal Audit in relation to other assurance activities within an organization. The role of Inspector General responsible for investigative matters (2 nd Line of Defense) and the role of CAE responsible for oversight over governance, risk management, and control mechanisms (3 rd Line of Defense) may present some potential impairment for Internal Audit. Management Response and Commitment to Action Standard No later than November 30, 2013, the responsibility to approve the Internal Audit Charter on an annual basis shall be added to Board policy. 2. No later than November 30, 2013, the responsibility to evaluate the performance of the Inspector General on an annual basis shall be added to Board policy. 3. No later than November 30, 2013, the Board Audit Committee s approval of the Annual Audit Plan shall be timely reported to the Board after the approval takes place, and the approval shall be documented in Board minutes. (Continued on next page) 10

11 Management Response and Commitment to Action Standard 1110 (Continued from previous page) 4. The Internal Audit Charter shall state that Internal Audit is free from interference in determining the scope of internal auditing, performing work, and communicating results. 5. The organizational independence of the Office of Inspector General shall be confirmed to the Board Audit Committee on an annual basis as required by Standard The Board Audit Committee shall evaluate the organizational structure of the Office of Inspector General with consideration given to the IIA Position Paper, The Three Lines of Defense in Effective Risk Management and Control (January 2013). The evaluation will determine the optimum organization of all assurance and compliance activities of HISD, including investigative matters, governance, risk management, and control mechanisms. The Board Audit Committee and Board shall evaluate the benefit of separating these functions and potential impairment or duplication of efforts. The Board of Education will complete this effort by December 31,

12 Conformance Gap Noted Standard 1210 Internal Audit management and staff generally do not have the knowledge of key information technology ( IT ) risks and controls and available technology-based audit techniques to perform their assigned work. There is only one IT auditor on staff with appropriate credentials and experience to demonstrate this proficiency. Associated Recommendations Standard Conduct training for all Internal Audit management and staff on the topic of IT risks, controls, and technology-based audit techniques to increase the overall level of awareness and proficiency for these concepts. Document consideration of IT risks, controls, and technology-based audit techniques in planning documentation for each engagement performed. 2. Evaluate the adequacy of Internal Audit resources with technical IT skills. Resources should correlate to the requirements derived from the annual risk assessment and audit planning process and should be sufficient to address the technology risk component of the annual audit plan. Consider the use of third party resources where internal resources are not sufficient or available. 3. Develop a Critical Knowledge and Skills Matrix to identify and document proficiency requirements within Internal Audit and to guide training and professional development where gaps exist. It is important for internal audit functions to ensure that the appropriate knowledge and skills are utilized on projects that may require specialized expertise. A critical knowledge and skills matrix defines the requirements by level in the organization and can be used as a tool when scheduling resources for individual projects. Gaps in the critical knowledge and skills matrix should be supplemented with additional internal resources or third party resources as appropriate. Management Response and Commitment to Action Standard The Office of Inspector General s management and staff must possess the knowledge, skills, and competencies necessary to perform their individual responsibilities. 2. The Office of Inspector General shall ensure training for all Internal Audit management and staff takes place periodically on the topic of IT risks, controls, and technologybased audit techniques to increase the overall level of awareness and proficiency for these concepts. The Office of Inspector General shall document consideration of IT risks, controls, and technology-based audit techniques in planning documentation for each engagement performed. These actions will be effective November 30, The Board Audit Committee and the Office of Inspector General shall evaluate the adequacy of Internal Audit resources with technical IT skills. The timing and resources shall correlate to the requirements derived from the Annual Risk Assessment and Annual Audit Planning. Resources shall be sufficient to address the technology risk component of the Annual Audit Plan. The Board Audit Committee shall consider the use of third party resources where internal resources are insufficient or unavailable. 4. The Office of Inspector General shall develop a Critical Knowledge and Skills Matrix to identify and document proficiency requirements within Internal Audit and to guide training and professional development where gaps exist. The Inspector General shall then report the findings to the Board Audit Committee. The Inspector General shall ensure that internal audit functions have the appropriate knowledge and skills utilized on projects that may require specialized expertise. A critical knowledge and skills matrix shall define the requirements by level in the organization and shall be used as a tool when scheduling resources for individual projects. Gaps in the critical knowledge and skills matrix shall be supplemented with additional internal resources or third party resources as deemed appropriate by the Board Audit Committee. 5. Except as noted in item 2, these actions shall be implemented by March 31,

13 Conformance Gap Noted Standard 1220 Internal Audit work papers do not fully support that all work is performed with due professional care. While a comprehensive work program generally supports work on each engagement and provides a level of structure within the work papers, documentation of engagement level risk assessment and planning is not in evidence. To demonstrate due professional care, planning documentation must include the consideration of the (1) extent of work needed to achieve the engagement s objectives; (2) the relative complexity, materiality, or significance of matters to which assurance procedures are applied; (3) adequacy and effectiveness of governance, risk management, and control processes; (4) probability of significant errors, fraud, or noncompliance; (5) cost of assurance in relation to potential benefits; and (6) the use of technology-based audit and other data analysis techniques. Associated Recommendations Standard Document engagement level risk assessment and planning and include in work papers for each engagement performed. At a minimum, planning must document the (1) extent of work needed to achieve the engagement s objectives; (2) the relative complexity, materiality, or significance of matters to which assurance procedures are applied; (3) adequacy and effectiveness of governance, risk management, and control processes; (4) probability of significant errors, fraud, or noncompliance; (5) cost of assurance in relation to potential benefits; and (6) the use of technology-based audit and other data analysis techniques. In addition, planning should document objectives and scope for the review as well as number and skill sets of resources assigned to the project consistent with the requirements of Standard Develop and implement planning and job completion checklists into an Internal Audit methodology to ensure audit engagements are planned and executed consistent with the defined methodology and that all required elements are considered. The use of checklists to plan, execute, and administer Internal Audit projects together with required supervisory review and approval (1) ensures consistent application of an Internal Audit methodology, (2) contributes to a high level of quality within Internal Audit projects, and (3) demonstrates due professional care in conducting internal audits. 3. Implement an electronic work paper tool, supported by planning and job completion checklists, to enhance efficiency, effectiveness, and quality of Internal Audit by ensuring consistent application of an Internal Audit methodology. This tool would provide the infrastructure to document all elements of an Internal Audit methodology from a due professional care perspective related to engagement planning, execution, reporting, and follow-up as well as documentation of supervisory review and approval. Electronic work paper tools support (1) knowledge sharing between audit teams; (2) reporting of established performance metrics to the Board and senior management; and (3) the efficient management of record retention requirements for Internal Audit work papers. Management Response and Commitment to Action Standard The Office of Inspector General s management and staff must apply the care and skill expected of a reasonably prudent and competent internal auditor. (Continued on next page) 13

14 Management Response and Commitment to Action Standard 1220 (Continued from previous page) 2. Effective November 30, 2013, the Office of Inspector General shall document engagement level risk assessment and planning, and it shall include work papers for each engagement performed. At a minimum, planning shall document: (1) the extent of work needed to achieve the engagement s objectives; (2) the relative complexity, materiality, or significance of matters to which assurance procedures are applied; (3) adequacy and effectiveness of governance, risk management, and control processes; (4) probability of significant errors, fraud, or noncompliance; (5) cost of assurance in relation to potential benefits; and (6) the use of technology-based audit and other data analysis techniques. Planning shall document objectives and scope for the review as well as number and skill sets of resources assigned to the project consistent with the requirements of Standard Effective November 30, 2013, the Office of Inspector General shall develop and implement planning and job completion checklists into an Internal Audit methodology to ensure audit engagements are planned and executed consistent with the defined methodology and that all required elements are considered. The use of checklists to plan, execute, and administer Internal Audit projects together with required supervisory review and approval (1) ensures consistent application of an Internal Audit methodology, (2) contributes to a high level of quality within Internal Audit projects, and (3) demonstrates due professional care in conducting internal audits. 4. The Office of Inspector General shall implement an electronic work paper tool, supported by planning and job completion checklists, to enhance efficiency, effectiveness, and quality of Internal Audit by ensuring consistent application of an Internal Audit methodology. This tool would provide the infrastructure to document all elements of an Internal Audit methodology from a due professional care perspective related to engagement planning, execution, reporting, and follow-up as well as documentation of supervisory review and approval. The Board Audit Committee agrees that electronic work paper tools support (1) knowledge sharing between audit teams; (2) reporting of established performance metrics to the Board Audit Committee and senior management; and (3) the efficient management of record retention requirements for Internal Audit work papers. This item will be implemented by March 31,

15 Conformance Gap Noted Standard 1300 The CAE has not developed, documented, or maintained a Quality Assurance and Improvement Program ( QAIP ) that covers all aspects of the internal audit activity and that is designed to evaluate (1) Internal Audit conformance to the Definition of Internal Auditing and the Standards; (2) whether internal audit management and staff appropriately apply the IIA Code of Ethics; and (3) the efficiency and effectiveness of the internal audit activity as well as identification of opportunities for improvement. Associated Recommendations Standard Establish, document, and maintain a QAIP that includes all required elements that include objectives, scope, internal and external assessment components, and communication requirements. The QAIP as a program is currently not formalized in a manner that ensures sustainability and consistent execution of all the required elements. The IIA Practice Guide Quality Assurance and Improvement Program (March 2012) provides strongly recommended guidance on the topic of a QAIP. The scope of the QAIP should be the operation of Internal Audit as described in the Internal Audit charter. Objectives for the QAIP should be consistent with those described in Practice Advisory and include: Conformance with the Definition of Internal Auditing, the Standards, and the Code of Ethics; Adequacy of the internal audit activity s charter, goals, objectives, policies, and procedures; Contribution to the organization s governance, risk management, and control processes; Compliance with applicable laws, regulations, and government or industry standards; Effectiveness of continuous improvement activities and adoption of best practices; and The extent to which the internal audit activity adds value and improves the organization s operations. Management Response and Commitment to Action Standard The Office of Inspector General in the capacity as Chief Audit Executive shall develop and maintain a Quality Assurance and Improvement Program ( QAIP ) that covers all the elements listed above. A QAIP shall be designed to enable the Board Audit Committee to evaluate the Office of Inspector General s conformance with the Internal Audit Charter. The QAIP shall also allow for the assessment of the efficiency and effectiveness of the internal audit activity and shall identify opportunities for improvement and a timeline for implementation. These actions will be implemented by June 30,

16 Conformance Gap Noted Standard 1311 Requirements for internal quality assessments are not defined and documented for Internal Audit as a component of a QAIP. Ongoing internal monitoring is an integral part of the day-to-day supervision, review, and measurement of the internal audit activity. Ongoing internal monitoring is incorporated into the routine policies and practices used to manage the internal audit activity and uses processes, tools, and information considered necessary to evaluate conformance with the Definition of Internal Auditing, the IIA Code of Ethics, and the Standards. While supervisory review and approval mechanisms are in place and working effectively, other aspects of ongoing internal monitoring are not defined or operating as required. Periodic internal assessments are not defined, documented, or performed as a component of a QAIP. The objectives associated with periodic internal assessments are to evaluate conformance with the Definition of Internal Auditing, the IIA Code of Ethics, and the Standards. Associated Recommendations Standard Define and document the requirements for ongoing internal monitoring as a component of a QAIP as described in the recommendation for Standard Currently, there are processes in place to support ongoing internal monitoring that include supervisory review and approval for all projects and a peer review by a second manager for major projects. Ongoing internal monitoring should also include the following: The use of checklists for engagement planning and completion to ensure the internal audit methodology is applied in a manner consistent with a defined Internal Audit methodology. The rigorous use of checklists also contributes to a demonstration that work is performed with due professional care as described in the recommendation for Standard The use of customer surveys to provide feedback on the effectiveness and value of the internal audit process. Surveys are typically used to identify opportunities to improve value, efficiency, and effectiveness of the internal audit process. The use of a balanced scorecard to measure and report key performance indicators to the Board on a periodic basis. Input from key stakeholders, including senior management and the Board, should be considered as key performance metrics comprising the balanced scorecard are being defined. The IIA Practice Guide Measuring Internal Audit Effectiveness (December 2010) should be considered as a resource when developing this approach. Using a balanced scorecard facilitates the communication of results of ongoing internal monitoring to the Board that is required on an annual basis under Standard Define and document the requirements for periodic internal assessment as a component of a QAIP as described in the recommendation for Standard The objectives for periodic internal assessment should focus on evaluating conformance with the Definition of Internal Auditing, the IIA Code of Ethics, and the Standards. Periodic internal assessment ensures that changes to Standards are incorporated into the methodology and infrastructure of Internal Audit in a timely manner and further provide an opportunity to evaluate attribute or performance components of the Standards in a more in-depth manner designed to improve efficiency and effectiveness of internal audit processes. Guidance on periodic internal assessment processes can be found in Practice Advisory Management Response and Commitment to Action Standard 1311 The Office of Inspector General will conduct internal assessments that include both ongoing internal monitoring and periodic self-assessment components. The Board Audit Committee will monitor performance of internal assessments by the Office of Inspector General. (Continued on next page) 16

17 Management Response and Commitment to Action Standard 1311 (Continued from previous page) 1. Effective June 30, 2014, the Office of Inspector General shall define and document the requirements for ongoing internal monitoring as a component of a QAIP as described in the recommendation for Standard While there are processes in place to support ongoing internal monitoring that include supervisory review and approval for all projects and a peer review by a second manager for major projects, ongoing internal monitoring shall also include: The use of checklists for engagement planning and completion to ensure the internal audit methodology is applied in a manner consistent with a defined Internal Audit methodology. The rigorous use of checklists also contributes to a demonstration that work is performed with due professional care as described in the recommendation for Standard The use of surveys to provide feedback on the effectiveness and value of the internal audit process. Surveys are typically used to identify opportunities to improve value, efficiency, and effectiveness of the internal audit process. The use of a balanced scorecard to measure and report key performance indicators to the Board Audit Committee on a periodic basis. Input from key stakeholders, including senior management and the Board Audit Committee, should be considered as key performance metrics comprising the balanced scorecard are being defined. The IIA Practice Guide Measuring Internal Audit Effectiveness (December 2010) should be considered as a resource when developing this approach. Using a balanced scorecard facilitates the communication of results of ongoing internal monitoring to the Board Audit Committee that is required on an annual basis under Standard Effective June 30, 2014, the Office of Inspector General shall define and document the requirements for periodic internal assessment as a component of a QAIP as described in the recommendation for Standard The objectives for periodic internal assessment should focus on evaluating conformance with the Definition of Internal Auditing, the IIA Code of Ethics, and the Standards. Periodic internal assessment ensures that changes to Standards are incorporated into the methodology and infrastructure of Internal Audit in a timely manner and further provide an opportunity to evaluate attribute or performance components of the Standards in a more indepth manner designed to improve efficiency and effectiveness of internal audit processes. Practice Advisory shall provide guidance on periodic internal assessment processes. 17

18 Conformance Gap Noted Standard 1312 Requirements for external quality assessment are not defined and documented for Internal Audit as a component of a QAIP as described in the recommendation for Standard External assessments must be conducted at least once every five years by a qualified, independent assessor or assessment team from outside the organization. The CAE must discuss with the Board the form and frequency of external assessment and the qualifications and independence of the external assessor or assessment team, including any potential conflicts of interest. Associated Recommendations = Standard Define and document the requirements for external quality assessment as a component of a QAIP as described in the recommendation for Standard Additional guidance related to external assessments can be found in Practice Advisories , , , and These requirements should at a minimum include: The form of the external assessment either a full scope review or a management self-assessment with independent validation. The frequency of the external assessment at least once every five years, although more frequent reviews are a leading internal audit practice. The evaluation of the qualifications of the external assessor or assessment team, including any potential conflicts of interest; and 2. Discussions between the CAE and the Board related to the form and frequency of the external assessment and the qualifications and independence of the external assessor or assessment team, including any potential conflict of interest. Management Response and Commitment to Action Standard 1312 The Internal Audit Charter shall require that an external assessment of Internal Audit be conducted at least once every five years without exception by a qualified independent assessor or assessment team from outside of the organization. 1. The Internal Audit Charter shall define and document the requirements for external quality assessment as a component of a QAIP as described in the recommendation for Standard The Board Audit Committee and the Office of Inspector General may also refer to additional guidance related to external assessments found in Practice Advisories , , , and The external assessment requirements shall include at a minimum: The form of the external assessment either a full scope review or a management self-assessment with independent validation. The frequency of the external assessment at least once every five years, although more frequent reviews are possible at the Board Audit Committee s discretion. The evaluation of the qualifications of the external assessor or assessment team, including any potential conflicts of interest. 2. The Office of Inspector General (as CAE), the Board Audit Committee, and Board shall discuss the form and frequency of the external assessment, the qualifications and independence of the external assessor or assessment team, and any potential conflict of interest. 18

19 Conformance Gap Noted Standard 1320 The requirements related to communication of results for internal and external assessments are not described in a QAIP. Specific communications related to the QAIP have not taken place as required. Associated Recommendations Standard Document the requirements related to communication of internal and external assessment results in a QAIP as described in the recommendation for Standard Communicate the results of external and periodic internal assessments upon completion of such assessments. Results must include the assessor s or assessment team s evaluation with respect to the degree of conformance with the Definition of Internal Auditing, the Code of Ethics, and the Standards. 3. Communicate the results of ongoing internal monitoring at least on an annual basis. Consider using the balanced scorecard approach described in the recommendation for Standard 1311 to facilitate this communication. Management Response and Commitment to Action Standard 1320 The Office of the Inspector General shall communicate the results of the QAIP to the Board Audit Committee. The Board Audit Committee shall make the Board aware of the results of the QAIP. 1. The Office of the Inspector General shall document the requirements related to communication of internal and external assessment results in a QAIP as described in the recommendation for Standard The Office of the Inspector General shall communicate the results of external and periodic internal assessments upon completion of such assessments. Results must include the assessor s or assessment team s evaluation with respect to the degree of conformance with the Definition of Internal Auditing, the Code of Ethics, and the Standards. 3. The Office of the Inspector General shall communicate the results of ongoing internal monitoring at least on an annual basis. The Board Audit Committee suggests the Office of Inspector General use the balanced scorecard approach described in the recommendation for Standard 1311 or another comparable and reliable performance measure to facilitate this communication. 19

20 Conformance Gap Noted Standard 1322 The CAE must disclose to senior management and the Board nonconformance with the Definition of Internal Auditing, the Code of Ethics, or the Standards when this impacts the overall scope or operation of the internal audit activity. Such communication has not taken place since this is the first external quality assessment performed for Internal Audit. The results of the current review concludes nonconformance with the Standards. Associated Recommendations Standard Disclose nonconformance with the Standards to senior management and the Board. 2. Monitor action taken to address nonconformance and report status to senior management and the Board on a periodic basis. 3. Conduct an external quality assessment when actions taken to address nonconformance are completed to assess level of conformance with the Standards. Management Response and Commitment to Action Standard No later than August 31, 2013, the Inspector General shall disclose nonconformance and the impact to the Board Audit Committee and senior management. The Office of the Inspector General must monitor action taken to address the nonconformance and provide the Board Audit Committee and senior management with status reports on a monthly basis. The Board Audit Committee shall also retain an independent and qualified assessor or assessment team to conduct an external quality assessment when actions taken to address nonconformance are completed to assess the level of conformance with the Standards. 20

21 Conformance Gap Noted Standard 2010 The process used to develop the annual risk assessment and associated annual audit plan does not meet all the requirements of Standard While an annual audit plan exists that is based upon a documented risk assessment, the level of detail supporting the annual audit plan and associated risk assessment is not sufficient to ensure an appropriate level of audit coverage with adequate resource requirements. There is a minimal level of input from senior management and the Board when conducting the risk assessment and developing the annual audit plan. The annual audit plan does not list specific projects to be performed, but rather lists broad areas of audit emphasis. An audit universe listing for all potential audit areas is not used during the process to ensure completeness of audit coverage. There is no linkage between the audit plan and resource requirements supporting the audit plan. The audit plan is not shared with senior management during or after the risk assessment and annual audit planning process. The process for risk assessment and annual audit planning is not formally documented to support consistency and sustainability. Associated Recommendations Standard Revise the risk assessment and annual audit planning process to align with the requirements of Standard 2010 and common internal audit practice. Use Practice Advisories (Linking the Audit Plan to Risk and Exposures) and (Using the Risk Management Process in Internal Audit Planning) to guide revisions. Include the following: Define and document a comprehensive audit universe derived in a systematic manner that provides assurance that all auditable entities are considered for the risk assessment process. Establish and document procedures to clearly link the annual audit plan with input from senior management and the Board to ensure the annual audit plan is linked to the entity-wide view of risk. Conduct a robust risk assessment that includes an IT risk component and which is applied to all areas of the audit universe to prioritize areas for review. Establish and define objectives for each project in the annual audit plan consistent with the overall risk assessment to guide internal audits at the engagement level. Discuss the results of the annual risk assessment with senior management and the Board to validate results. Review the annual audit plan with senior management and the Board prior to finalization. Provide a copy of the annual audit plan to senior management and the Board. 2. Include sufficient detail in the annual audit plan to link the annual plan requirements with Internal Audit resource requirements. The annual audit plan should include a listing of specific projects to be completed and the associated time needed to complete the project vs. available hours based on staffing levels to determine adequacy. 3. Document the annual risk assessment and audit planning process to ensure consistency and sustainability of the process. Management Response and Commitment to Action Standard 2010 Concurrent with the development of the Annual Audit Plan, the Office of Inspector General, under supervision and approval by the Board Audit Committee, shall establish a risk-based plan to determine the priorities of the internal audit activity that is consistent with HISD s goals. (Continued on next page) 21

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